Chin Jing Jih: 'Integration is healthcare system's holy grail'

SINGAPORE - In Part 2 of this Supper Club interview, Associate Professor Chin Jing Jih, director of the Institute of Geriatrics and Active Ageing and divisional chairman (Integrative and Community Care) at Tan Tock Seng Hospital, debunks some myths about the elderly's health-care needs and reveals what he thinks the holy grail of eldercare here should be.

Q: What are the top few misconceptions that people may have about the elderly and their healthcare needs?

A lot of times, people think that seniors are too old to benefit from any health-care intervention. The other misconception is that the elderly are illiterate and cannot understand what's happening, so they are left out of decisions.

That is something that should change and is certainly going to change because our subsequent cohort of old people, the baby boomers, are far more educated and far more resourceful. It certainly would become very clear that it's very disrespectful to leave them out of that entire conversation.

I don't deny that treatment decisions are sometimes family decisions. But it is wrong to leave these seniors out of the decision-making. We should try our best to involve them. Once you involve them, you are able to include them in setting the goals they desire for that phase of their life and then see what's appropriate for them.

A lot of times, there are interventions that may not improve their quantity of life but may actually improve their quality of life. But the conversation has to be able to inform them, if they do this, what benefits it will bring them in terms of quality of life.

The old people also need to know that they are able to make that decision. One of the key things of this Pioneer Generation Package for me is that, if I'm an old person and the doctor now offers me a treatment, in the past, I would look at my children and wonder, can they afford it? Am I going to burden them? At least now I don't have to turn my head, I can think whether this outcome is something I want.

We must also contextualise the treatment for them and not assume that there's no point talking to them about treatment and interventions. That is a kind of ageism which sidelines old people from decision-making and because of that, they are not offered the appropriate treatment.

Q: Could you give examples of some decisions the elderly could be more involved in?

One example is when they come to the clinic and say, my knee hurts whenever I walk. Nowadays, it's quite common to do a total knee replacement. But the family may say there's no point discussing it, either because they are old or they won't want surgery. But that conversation needs to take place. Even if they do not want it in the end, at least it's an informed decision. It's part of respecting them and not making too many assumptions.

You'd be amazed at how many of the elderly actually refuse cataract surgery. That is an example of how we musn't be too presumptuous - "she hardly reads, she can see the shadows on the TV, that's good enough". But if you can persuade them, it's like a new lease of life. It changes their perspective completely.

They suddenly become more positive because it's very enabling. They are now able to do a lot of things. So we need to hear the voice of the old person. We need to know for this particular old person, what is it they still desire to do, can this intervention help them, and then have a very reasonable discussion.

Q: How can the health-care system improve to help seniors attain their aim of ageing at home?

If you look at the history of our health-care system, in the 1960s, there were a lot of successful public health initiatives that improved survival, reduced infant mortality, prolonged the lifespan and moved us from the profile of a third-world country to second- and first-world.

Then in the 80s and 90s, the investment was mainly in tertiary care, specialist care, hospitals. We sent our brightest doctors overseas to train as specialists, and they were able to overcome a lot of diseases previously considered incurable. The effect of that is we now have an ageing population where fewer people die young, but they have chronic diseases that they carry with them.

While we are still continuing to invest in specialist care, there is a need to balance it with investment in primary and community care and more importantly, to integrate with it. The ultimate holy grail is that we become one system of shared accountability, where more people use primary and community care, and the hospital is used only when the illness is beyond the expertise of primary care. This way, the hospital can be decongested with beds always available during a medical emergency.

I think there also needs to be a relook at the whole system because seniors tend to have different needs. A lot of seniors have multiple problems and they may end up seeing many specialists, but the care has also got to be coordinated. Because at the end of the day, you're not treating the diseases, you're treating the person. So we also need to recognise the importance of training generalists, because the generalist is able to have the full picture and know when to send a person to a specialist. The specialist solves a particular problem, but you need somebody who's overall-in-charge.

A third framework is also job reconstruction, in the sense that all health-care professionals now need to look at their job scope and say, can some of these be transferred to a less skilled person while I focus on the more difficult work? That will help increase productivity. Our workforce can't expand as fast as the ageing population, so we need to look at how to best use expertise. For example, if there can be a system of transferring more stable patients to primary care, then the specialist will have more time to do either research innovation or look at a more difficult group of patients.

We also need to get Singaporeans interested in the health-care industry. That requires a lot of planning and I know there are a lot of government initiatives in the pipeline. Otherwise if you have this wonderful Pioneer Generation Package but there are not enough health-care workers when people come to hospital, it's also a problem.

Q: Is it going to be a challenge to convince medical students to consider a more general path?

Actually, if you look at every cohort, the majority end up as either general practitioners or generalists in the hospital. So that's happening already. But what we need to do is to equip people better to become a generalist. The change in emphasis is important, as is the amount of time set aside in the medical undergraduate curriculum and the mindset and framing. For example, a posting in renal medicine. In the past, the students may spend all their time following a renal specialist, looking at how to manage patients in the hospital.

The syllabus now needs to apportion adequate time and exposure to: What happens to these patients when they go home? How does a GP help to look after a patient with chronic renal failure? How does a GP help to pick up kidney diseases early in the community? How does the hospital, the GP and community dialysis service share a common accountability for the patient?

Q: You spoke of how the holy grail is for the whole system to be integrated and operate as one entity. How is Tan Tock Seng, for instance, trying to do that?

In Tan Tock Seng, we started the journey towards the end of 2008. We have the oldest geriatric medicine department so there's greater sensitization to some of these problems that are coming. We know that waiting for seniors to come to the hospital is never the best approach. We know that a lot of them also avoid coming to the hospital. So in 2008, we got the department of continuing and community care to go into the community. We provided care for patients who were discharged from hospital and were very frail and at risk of coming back, provided advanced care planning for those in nursing homes and went around screening for people that we knew were at risk of falls but were not seeing a doctor. We also tried to form a network with existing care providers, mainly the VWOs, and tried to connect everybody so that we all know of each other and what we are doing.

We realised that for a lot of old people, there are a lot of social issues behind their medical issues. So it could be very frail social structures - nobody to remind them to take their medication, nobody to bring them to come for appointments so they miss their appointments. It could be that their light bulb is dim or malfunctioning and they don't know how to change the bulb (which might increase the risk of falls). We're now also starting to connect with the social sector as for a lot of old people, it is not so easy to tease out the medical and social problems. You need a team approach, otherwise you actually end up over-servicing a person because both the medical and social teams are visiting him, or some people have nobody to visit them at all.

All this wil bring care to the community at an earlier stage and help seniors age in place. At the end of the day, what should happen is a seamless sharing of resources and accountability. Eventually, we should all work towards a "one system" sort of framework. It would then lead to wiser use of the Pioneer Generation Package and make it more sustainable.

Q: What about later stages of care like step-down care and the intermediate to long-term care sector, which are not covered by the Pioneer Generation Package?

I think these must be brought in. Because if you don't include these, then people who need to go to step-down care or intermediate to long-term care may resist if they have to pay out of their pocket. We need to have a system that nudges the right kind of behaviour. In other words, if you go to an acute hospital, once your catastrophic phase is over, it's time to move to the next care setting that best serves your needs and then after you finish, you move on.

Initially, one of my reservations about MediShield Life was that it is insurance. A lot of the time, people talk about insurance as a contractual entitlement: I've paid the premiums so now you're duty-bound to give me the service. The key to that is actually the professionals advocating the right kind of service and including the seniors in the discussion of what is the appropriate treatment for their phase in life. We need to further refine the whole system, such that it becomes a logical conclusion for people to say, okay, I've no more need to be here, I should move down to sub-acute care or a community hospital.

Q: But the decision to move down is not always about logic. A common anecdote is the stricter means testing for step-down care, which can lead to some people staying on in hospitals because they end up paying less.

That's right. But when you look at the whole system, it doesn't make sense. At the end of the day, if people don't move, the whole system ends up paying more money because the person is over-staying in the acute care sector. This is where the innovation is going to take place, to see how we can make some of these subsidies more portable and have the right incentives or disincentives to nudge the right kind of behaviour.

Q: Are you confident that we are moving in that direction?

I think we have no choice. I'm confident because I know that being a very pragmatic nation, we have often been able to think of ingenious ways to overcome things. And this is not really difficult, it's just tweaking the existing system. For example, when I was in the US many years ago, I was amazed at how willing the acute patients were to move to community rehab even though they're on medical insurance. I was told that if they are fit to go and they're willing to go, the insurance will then transfer the money to pay for the rehab because the insurance company is a single payer. Here, it's the same payer as well - the Government. As long as it's the same payer, it's not a difficult thing to do.

Q: So in a sense, we have to be more flexible in how we use the insurance system?

Yes. We need to introduce flexibility that is guided by sound principles and transparency. I think with transparency, a lot of problems solve themselves and people will make the sound, logical decision that is good for everybody.

Q: One argument is, if you make Medisave and MediShield more flexible, will that be financially sustainable or will it end up in government and taxpayers spending more?

I think people need to recognise that acute care is actually the most expensive. As long as people who do not need acute care promptly move to an appropriate care setting, there's going to be tremendous savings.

I think the fear about the insurance system is that it's like a buffet - everybody rushes for the oysters because it's the most expensive thing and because they've paid the entrance fee, they feel entitled to the oysters. But I think in health-care, it's different. You have the professionals there to say, hey, look, you shouldn't be eating oysters. You should be eating the greens. So there is some rationality about this system and I think it's whether we advocate the right kind of intervention for the right phase of the treatment.

For example, let's say we have a patient who already has advanced dementia and is bed-bound. The doctor will say right away that a total knee replacement doesn't make sense, he's not walking anymore. So there is a safeguard where we will use an intervention appropriately, only for those who will benefit.

Let's say you see an increase in total knee replacements. What we should see is, these are the people who need the total knee replacement and will benefit, but at the moment they are not doing it because they think they can't afford it. If that leads to an increase in claims, we shouldn't be worried, because we have the bigger picture in mind. If this guy now has a total knee replacement, he's going to be more ambulant and that will improve his cardiovascular health. It's just more indirect.

So if you look at the long term, the whole system, there are a lot of arguments against a totally negative perspective of insurance coverage. It's just that the utilisation has got to be wise and aligned with patients' choices and goals of care.

Q: Personally speaking, would you say Singapore is a good place to grow old in?

I think it is, but more can be done. What is good is you actually see a desire to do better. There is lots of evidence that the Government is conscious of the issues and they are trying their best to encourage innovation and tweak their policies to make this an elder-friendly environment.

I think it depends on whether you're an optimist or pessimist. As an optimist, one of the most important things is whether society recognises the old people as an integral part of itself, or whether you are just a machine that is used and now no longer productive, to be tucked in a corner.

The Pioneer Generation Package is a very strong statement that this Government is concerned about its elderly and is willing to put its money where its mouth is. That sends a great message to the young about the inter-generational compact and solidarity. In the past, you hear a lot about investing in the younger generation for the continuity of the nation. That hasn't stopped. But I think respecting the old and transferring resources to the next generation do not have to be mutually exclusive. It doesn't mean that if you transfer to the next generation, we won't be able to look after the old. Our Government has invested wisely and we are, if anything, one of the countries with the resources to do that.

Some fear that the package will tell people, "don't worry, if you're not filial, I will take over your job". I disagree and take the view that the package is not meant to substitute the duties of children in providing for the healthcare of their parents. On the contrary, the message is something like "even the Government is now helping, you jolly well also preserve this virtue called filial piety that is very much valued by society". It is not like some societies where young and old are competing for resources. It is a sharing of resources in the right proportion.

The other thing I'm very happy about is the package sends a very valuable signal to the young that as a small country, we need to have that compact between young and old. Otherwise, you can imagine, we have an ageing population, the young will get very disenfranchised thinking that "all my hard work will end up supporting the old". In some countries, we already see that taxation is high, but we are fortunate because we have Oriental roots and we use family bonds to bring the young and old generations together.

Q: Higher taxation may very well happen in the near future.

It may happen. That's why I think all the other healthcare innovations have to take place so that we are more productive and at the same time, our population can be old but not sickly. That will help to lower the burden on the young. What is important is that as we prolong lifespan, the quality of life is good, the healthy years are prolonged and we compress the years of morbidity. That's why it's not just a financing issue. It's the overall package that we need to take care of - otherwise $80 billion will also not be enough!

I think we can have a more balanced and optimistic perspective. Sometimes we have to take the first step, trudge along and do fine tuning, otherwise we'll never move.

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